Davis In-Home Care Employment Application

By SUBMITTING this application, you certify that the information provided in this application is true and correct to the best of your knowledge, and that you have read and agree to Davis In-Home Care, Inc. application terms.

* indicates Required Information

POSITION APPLYING FOR:
DATE DATE / MM / DD YYYY
Contact Information
Name Name First Last
Have you used another name? If so, list:
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Have you lived in any other countries or states in the past 7 years? If so, please list with dates:
Home Phone #: Home Phone #: - ### - ### ####
Cell Phone #: Cell Phone #: - ### - ### ####
Best contact number

Best contact number Home Cell
May we also contact you via email?

May we also contact you via email? Yes No
If so, please provide email address:
Are you at least 18 years of age?

Are you at least 18 years of age? Yes No
If under 18, can you submit a work permit?

If under 18, can you submit a work permit? Yes No
Do you have the legal right work in the United States?

Do you have the legal right work in the United States? Yes No
This position requires driving. Do you have your own car, a valid California driver's license and insurance?

This position requires driving. Do you have your own car, a valid California driver's license and insurance? Yes No
The State of California 2016 Home Care Services Consumer Protection Act (HCSCPA) requires that all non-medical caregivers working for a registered HCO (Home Care Organization) supply the following 3 documents. Do you have:
Live Scan Fingerprinting

Live Scan Fingerprinting Yes No
Current TB Test

Current TB Test Yes No
HCA Registration

HCA Registration Yes No
How did you learn about this position?

How did you learn about this position? Google Search Craigslist Indeed Care.com School Friend Newspaper Job Board Agency Current Employee EDD Other Other
Education
High School Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
# of Years Attended
Did You Graduate?

Did You Graduate? Yes No
Degree/Major
Junior College Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
# of Year Attended
Did You Graduate?

Did You Graduate? Yes No
Degree/Major
College or University Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
# of Year Attended
Did You Graduate?

Did You Graduate? Yes No
Degree/Major
Other School Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
# of Year Attended
Did You Graduate?

Did You Graduate? Yes No
Degree/Major
Other training, certificates or special skills?
Experience
Discuss any training or experience working with the elderly.
What would you like most about working with the elderly?
How many years of experience do you have working with the elderly?
Skills

Please indicate whether you have assisted with or performed the following tasks for seniors.
Companionship

Companionship Yes No
Vacuuminng

Vacuuminng Yes No
Laundry

Laundry Yes No
Bathing

Bathing Yes No
Dusting

Dusting Yes No
Grocery Shopping

Grocery Shopping Yes No
Grooming or Dressing

Grooming or Dressing Yes No
Clean Bathrooms

Clean Bathrooms Yes No
Cooking

Cooking Yes No
Incontinence

Incontinence Yes No
Clean Kitchen

Clean Kitchen Yes No
Driving

Driving Yes No
Transfer Assist

Transfer Assist Yes No
Bed Linen Changes

Bed Linen Changes Yes No
Medication Reminders

Medication Reminders Yes No
Please review the tasks above. Are you able to perform the essential functions on this job, either with or without reasonable accomodation?

Please review the tasks above. Are you able to perform the essential functions on this job, either with or without reasonable accomodation? Yes No
NOTE: We comply with the ADA and FEHA and consider reasonable accommodation measures that may be necessary for eligible/qualified applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and skill and agility tests, based on the job requirements.

If no, describe the functions you cannot perform:
Additional Information
Days and times you are available to work
Number of hours you would like to work each week?
Times you are NOT AVAILABLE to work
Date you can start Date you can start / MM / DD YYYY
Desired Pay per Hour
Foreign Languages: proficiency to speak, read or write?
Employment History

Starting with your most recent employer, list at least 4 work references we can call, even if they are not related to caregiving.
Employer Name #1
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employed From Date Employed From Date / MM / DD YYYY
Employed To Date Employed To Date / MM / DD YYYY
Job Title
Reason for Leaving
Duties
Supervisor
Phone Phone - ### - ### ####
May we contact this employer?

May we contact this employer? Yes No
Employer Name #2
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employed From Date Employed From Date / MM / DD YYYY
Employed To Date Employed To Date / MM / DD YYYY
Job Title
Reason for Leaving
Duties
Supervisor
Phone Phone - ### - ### ####
May we contact this employer?

May we contact this employer? Yes No
Employer Name #3
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employed From Date Employed From Date / MM / DD YYYY
Employed To Date Employed To Date / MM / DD YYYY
Job Title
Reason for Leaving
Duties
Supervisor
Phone Phone - ### - ### ####
May we contact this employer?

May we contact this employer? Yes No
Employer Name #4
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employed From Date Employed From Date / MM / DD YYYY
Employed To Date Employed To Date / MM / DD YYYY
Job Title
Reason for Leaving
Duties
Supervisor
Phone Phone - ### - ### ####
May we contact this employer?

May we contact this employer? Yes No
Additional Professional References (if available)

If possible, list additional employers we can call. Or, list co-workers or others who know your work. Please do not duplicate references from above.
#1 Supervisor, co-worker or other
Business name/Position
Years known
Phone Phone - ### - ### ####
#2 Supervisor, co-worker or other
Business name/Position
Years known
Phone Phone - ### - ### ####
#3 Supervisor, co-worker or other
Business name/Position
Years known
Phone Phone - ### - ### ####
Personal References

Please do not list relatives as personal references, nor duplicate references from above.
Name Name First Last
City/State
Relationship/Years Known
Phone Phone - ### - ### ####
Name Name First Last
City/State
Relationship/Years Known
Phone Phone - ### - ### ####
Name Name First Last
City/State
Relationship/Years Known
Phone Phone - ### - ### ####

Davis In-Home Care Employment Application

Davis In-Home Care Employment Application

Contact Information

The State of California 2016 Home Care Services Consumer Protection Act (HCSCPA) requires that all non-medical caregivers working for a registered HCO (Home Care Organization) supply the following 3 documents. Do you have:

Education

Experience

Skills

Additional Information

Employment History

Additional Professional References (if available)

Personal References